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SAN JOAQUIN CONTY ENVIRONMENTAL HEALTH Do"MENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> U-�f ri!�QEj b 2 S/?-bb v 6�2 <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE A DRESS 3 C^C IC- 7-OI� "Oad ��Y\ 1J 53 (,6 <br /> 5o ( Street Number Irectlon Str et Naml— c1tv Zip ode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> ber St <br /> Street Numreet Name <br /> CITY STATE ZIP <br /> PHONE#'I ExT• APN# LAND USE APPLICATION# <br /> (I" ) 5f - (-//L(( <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS❑ <br /> leap� 1/2da �l /2 <br /> BUSINESS NAME PHONE# ExT' <br /> HOME or MAILING ADDRESS FAX# <br /> 6,77 ( 2©9 ) 307- Isy3 <br /> CITY L9 ,._,/ ,' STATE C'ko ZIP q S 3 (16 <br /> BILLING A�CKNO-WLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. // <br /> APPLICANT'S SIGNATURE: DATE: `7 l U�� <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: PAYMENT <br /> COMMENTS: <br /> Arid 2 0 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: G EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: / P/E: <br /> ere _ Amount Paid Payment Date <br /> Payment Type Invoice# Check# l'� S Received By: k� (� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />